Significant Cardiac Events Research Articles

Patient Recovery and Transitions After Hospitalization for Acute Cardiac Events

Despite increased attention to providing seamless transitions after hospitalization, patients often feel unprepared, lack knowledge, and may be confused by what to expect during recovery at home after a cardiac event. Care transition after hospital discharge could be improved by informing and counseling patients more specifically about expected recovery after a cardiac event. Therefore, an integrative review of research was conducted to evaluate cardiac patients' trajectory of recovery after hospitalization. A total of 61 studies were included in this review. Studies included were those of cardiac patients who had been hospitalized for significant cardiac events and those focused on acute coronary syndrome (n = 18), percutaneous coronary intervention (PCI) (n = 12), cardiac surgery (coronary artery bypass surgery and valve surgery; n = 25), and heart failure (n = 6). Studies included quantitative, mixed-methods, and qualitative designs, with sample sizes ranging from 4 to 2121 participants. Notwithstanding the limitations of this review, findings demonstrated that patients' perceptions of their cardiac event evolved over time from uncertainty, fears, anxiety, and depression, which were often associated with a lack of knowledge of their cardiac condition, to a phase of self-management of their cardiac condition. Furthermore, patterns of commonly occurring symptoms and changes in functioning abilities during recovery after hospitalization were apparent among the different cardiac groups. These findings may be useful to both patients and clinicians to inform them about the recovery trajectory after a cardiac event to improve preparation for the transition from hospital to home.

Gamma-glutamyltransferase in acute coronary syndrome patients without ST elevation and its association with stenotic lesion and cardiac events

There are limited data on prognostic value of gamma-glutamyltransferase (GGT) in acute coronary syndromes (ACS) with non-ST-segment elevation (NSTE-ACS). We investigated GGT levels and their association with significant stenosis and major cardiac events (MACE) in NSTE-ACS patients. This study included 237 patients with NSTE-ACS (ACS group), and age-matched and sex-matched controls with normal coronary arteries (control group). ACS group was divided into subgroups with and without significant stenosis. Serum creatine kinase-MB, troponin T and GGT levels were measured. ACS patients were followed up for MACE (composite of cardiac death, myocardial infarction, recurrent angina, and hospitalization) during 12 months. Median GGT level was higher in ACS group than control group (32 vs. 16 U/l, P=0.001). NSTE-ACS was independently associated with hypertension [odds ratio (OR): 2.83, P=0.001], smoking (OR: 2.19, P=0.015), GGT [OR: 1.16, 95% confidence interval (CI): 1.11-1.21, P=0.001] and ejection fraction (OR: 0.92, P=0.01). GGT level was also higher in patients with significant stenosis than those without significant stenosis (37 vs. 22 U/l, P=0.001). Presence of significant stenosis was independently associated with GGT level (OR: 1.17, 95% CI: 1.12-1.23, P=0.001). At 12 months, MACE-free survival was slightly poor in ACS patients with upper GGT tertile compared with those with lower GGT tertile (77 vs. 97%, P=0.06). In NSTE-ACS patients, increased GGT levels can be associated with significant stenosis and MACE.

Black Esophagus

To the Editor.—I read with great interest the article by Altenburger et al1 on black esophagus. The authors describe unusual autopsy findings in a 45-year-old woman with a history of cocaine and alcohol abuse and believe that the cause of death was acute necrotizing esophagitis. Black esophagus is a rare disease characterized by circumferentially appearing necrosis of the distal esophagus that extends proximally and may involve the entire length of the organ. Its etiology is usually multifactorial, including ischemic phenomenon, chemical injury to the tissue from gastric contents, and a decrease in effective mucosal defense barriers. Mortality is high because of underlying medical conditions (cardiovascular disease, sepsis, malignancy, and multiorgan failure remain major risk factors for the development of black esophagus and for patient fatality) but is not directly related to the esophageal disease, except in the rare cases of perforation, mediastinitis, and esophageal infection in immunocompromised individuals.2 Chronic cocaine and alcohol abuse will easily trigger a significant cardiac event, such as arrhythmia, a more likely cause of death in this patient, with a rather incidental finding of black esophagus.

Improving Patient Flow in Acute Coronary Syndromes in the Face of Hospital Crowding

BackgroundThe current paradigm for the evaluation of patients with suspected acute coronary syndromes (ACS) in the emergency department (ED) is focused on the identification of patients with active underlying coronary disease. The majority of patients evaluated in the ED setting do not have active underlying cardiac disease. ObjectiveTo measure the effect of bedside point-of-care (POC) cardiac biomarker testing on telemetry unit admissions from the ED. Furthermore, to evaluate the effect telemetry admissions have on ED length of stay (LOS) and overall hospital LOS. MethodsPrimary data were collected over two 6-month periods in an urban teaching hospital ED. This was an observational cohort study conducted pre- and post- availability of a POC testing platform for cardiac biomarkers. Major measures included number of overall telemetry admissions, ED LOS, hospital LOS, and disposition. Patients were followed at 30 days for significant cardiac events, repeat ED visit or admission, and death. ResultsIn the post-implementation period there was a 30% (95% confidence interval [CI] 36–44%) reduction in admissions to telemetry with a 33% (95% CI 26–39%) reduction in ED LOS and a 20% (95% CI 7–34%) reduction in hospital LOS. There was a 62% reduction in overall mortality between the pre-implementation period and the post-implementation period (p=0.001). ConclusionThe focused use of a rapid cardiac disposition protocol can dramatically impact resource utilization, expedite patient flow, and improve short-term outcomes for patients with suspected ACS.

Possible effects and changes of myocardial injury markers in percutaneous coronary intervention

Possible effects and changes of myocardial injury markers in percutaneous coronary intervention

How the latest evidence from clinical research informs patient care

How the latest evidence from clinical research informs patient care

Nonsense-mediated mRNA decay caused by a frameshift mutation in a large kindred of type 2 long QT syndrome

Nonsense and frameshift mutations are common in congenital long QT syndrome type 2 (LQT2). We previously demonstrated that hERG nonsense mutations cause degradation of mutant mRNA by nonsense-mediated mRNA decay (NMD) and are associated with mild clinical phenotypes. The impact of NMD on the expression of hERG frameshift mutations and their phenotypic severity is not clear. The purpose of this study was to examine the role of NMD in the pathogenesis of a hERG frameshift mutation, P926AfsX14, identified in a large LQT2 kindred and characterize genotype-phenotype correlations. Genetic screening was performed among family members. Phenotyping was performed by assessment of ECGs and LQTS-related cardiac events. The functional effect of P926AfsX14 was studied using hERG cDNA and minigene constructs expressed in HEK293 cells. Significant cardiac events occurred in carriers of the P926AfsX14 mutation. When expressed from cDNA, the P926AfsX14 mutant channel was only mildly defective. However, when expressed from a minigene, the P926AfsX14 mutation caused a significant reduction in mutant mRNA, protein, and hERG current. Inhibition of NMD by RNA interference knockdown of up-frameshift protein 1 partially restored expression of mutant mRNA and protein and led to a significant increase in hERG current in the mutant cells. These results suggest that NMD is involved in the pathogenic mechanism of the P926AfsX14 mutation. Our findings suggest that the hERG frameshift mutation P926AfsX14 primarily results in degradation of mutant mRNA by the NMD pathway rather than production of truncated proteins. When combined with environmental triggers and genetic modifiers, LQT2 frameshift mutations associated with NMD can manifest with a severe clinical phenotype.

Anesthesia for videoscopic left cardiac sympathetic denervation in children with congenital long QT syndrome and catecholaminergic polymorphic ventricular tachycardia – a case series

To describe our experience in the anesthetic management of pediatric patients who have undergone left cardiac sympathetic denervation (LCSD) for congenital long QT syndrome (LQTS) and catecholaminergic polymorphic ventricular tachycardia (CPVT). Long QT syndrome and CPVT predispose patients to ventricular arrhythmias and sudden death. One treatment option for these patients is LCSD. When these patients present for LCSD or other surgical procedures, anesthetic management is challenging, as many medications may exacerbate QT prolongation. Retrospective review of the electronic medical records of 22 pediatric patients who underwent LCSD between November 2005 and December 2008. Six patients (27%) received midazolam as a premedication. Eleven patients (50%) underwent inhalation induction with sevoflurane. Eighty-six percentage received either sevoflurane or isoflurane for maintenance of anesthesia, while the remaining 14% received a propofol infusion. Nine patients (41%) received esmolol infusions intraoperatively, while one patient (4.5%) received a labetalol infusion. Three patients (14%) received lidocaine infusions. no significant cardiac or other events occurred in any of these patients in the perioperative period. Important anesthetic considerations in this population include avoidance of sympathetic stimulation, correction of any abnormal electrolytes, and the immediate availability of a defibrillator and magnesium sulfate to treat arrhythmias. Anxious patients may benefit from premedication to reduce sympathetic tone. We have safely used both volatile agents and propofol for induction and maintenance of anesthesia. In our experience, intraoperative infusions of beta-blockers and lidocaine seem to be helpful in reducing arrhythmogenic potential, especially in patients with profound QT prolongation.

An unusual cause of dyspepsia: oesophageal cavernous haemangioma

A 73-year-old gentleman presented to his local general practitioner with a sudden onset history for 24 h of dyspepsia. The symptoms were exacerbated with food over the period. He was referred to the medical assessment unit at The Horton Hospital, Banbury, UK. His medical history included: hypertension (on enalapril) and asthma (on a salbutamol inhaler as required). He was a retired construction manager who had worked for a long period in The Middle East and Japan. He took 2–3 cans of beer and 2–3 glasses of wine per week. He had been noted to have longstanding mildly abnormal liver function tests 12 years prior to admission with a predominantly elevated γ-GT. A chronic liver disease screen and ultrasound arranged previously at a private clinic had been unremarkable. In the medical assessment unit, clinical examination was unremarkable. His blood tests (including a Troponin to exclude significant cardiac event), electrocardiograph and chest X-ray were normal. He was started on a proton pump inhibitor with an outpatient gastroscopy requested. A gastroscopy was carried out 2 weeks later performed by a general practitioner (GP) endoscopist with the squamocolomnar junction seen at 36 cm with a 4-cm hiatus hernia. An abnormal …

Transient cardiac ischaemia and abnormal variations in systemic blood pressure in unselected primary open angle glaucoma patients

To investigate the relationship between the occurrence of transient cardiac ischaemic episodes and variations in the ambulatory 24-h blood pressure and heart rate measurements in a group of unselected glaucoma patients. Prospective study. Twenty-four consecutive glaucoma patients and 23 age-matched controls were included in the present study. The participants were subjected to an ambulatory 24-h blood pressure and electrocardiogram monitoring. The number and duration of transient cardiac ischaemic events as well as the longest ischaemic event (LIE) and its relationship to the recorded systemic blood pressure (BP) and heart rate (HR) values were also analyzed. Overall, in glaucoma patients, LIE was also associated with a significant increase in diastolic and mean BP (p = 0.007 and p = 0.003 respectively) and HR (p = 0.007). However, six glaucoma patients (46.86%) failed to demonstrate any significant BP changes during the LIE (p > 0.05). Four of these patients also failed to demonstrate any significant HR changes during the LIE (p > 0.05). As opposed to age-matched controls, in glaucoma patients the systemic circulatory responses associated with significant transient cardiac ischaemic events were highly variable.

205 ST segment changes after external cardioversion using direct current shock: incidence, characteristics and predeictive factors

DC shock is commonly used for external cardioversion of cardiac arrhythmias. Incidence, characteristics and predictive factors of transient ST-segment changes after DC shock are poorly known. 91 consecutive pts referred for external cardioversion of atrial fibrillation (AFib) (61 men, 69 ± 10 yo) were prospectively included. Duration and amplitude of ST elevation or depression were quantified on12 lead-ECG immediately after the first DC shock. Correlations with DC shock characteristics clinical variables, underlying heart disease, echocardiographic parameters, biological parameters, medications, anesthesic drugs as well with morphological features were made. 18 and 20 pts underwent 200 J or 300 J monophasic and 53 pts 200 J biphasic DC shocks. Immediate success rate was 95%.We found an incidence of 48% for ST segment changes: 35% for ST elevation (0,81 ± 0,44 mV) and 13% for ST depression (0,2 ± 0,07 mV, p<0,0001). ST changes were essentially seen in the right precordial leads. Major ST elevation was observed in 27% which could sometimes display Brugada-like pattern. ST changes durations were similar for ST elevation and ST depression (60 ± 43 vs 50 ± 26 sec, p=ns) and were correlated to the amplitude of ST changes. ST changes did not induce significant cardiac events or alter immediate or late AFib recurrences. ST changes were not related to energy but ST elevation was significantly more often induced by monophasic (76% vs 6%, p<0,0001) and ST depression by biphasic DC shocks (26% vs 3%, p=0,01). Using multivariate analysis, independent predictors for ST elevation were the use of monophasic DC shocks, use of propofol and increased CRP, while a low ejection fraction and use of biphasic DC hocks were independent predictors of ST depression. ST segment changes after external cardioversion with DC shock are common, short living and do not seem to carry clinical significance. They are related to the monophasic or biphasic configuration of DC shock, to the use of propofol, to the ejection fraction and to an increased CRP. Direct membrane injury by electroporation is suspected.

ST-segment changes after direct current external cardioversion for atrial fibrillation. Incidence, characteristics and predictive factors

Background Incidence, characteristics and predictive factors of transient ST-segment changes after DC shock are poorly known. Methods 91 consecutive pts referred for external cardioversion of atrial fibrillation (AF) (61 men, 69 ± 10 yo) were prospectively included. The presence of ST elevation or depression was assessed on 12 lead-ECG immediately after the first DC shock. Correlations with DC shock characteristics (monophasic/biphasic and energy), clinical variables, echocardiographic parameters, biological parameters, medications, anesthesic drugs as well with morphological features were made. Results 18 and 20 pts underwent 200 J or 300 J monophasic and 53 pts 200 J biphasic DC shocks. We found an incidence of 48% for ST-segment changes: 35% for ST elevation and 13% for ST depression. ST changes did not induce significant cardiac events or alter AF recurrences. ST changes were not related to energy but ST elevation was significantly more often induced by monophasic (76% vs 6%, p < 0.0001) and ST depression by biphasic DC shocks (26% vs 3%, p = 0.01). Using multivariate analysis, independent predictors for ST elevation were the use of monophasic DC shocks, of propofol and increased CRP, while a low ejection fraction and use of biphasic DC shocks were independent predictors of ST depression. Conclusion ST-segment changes after external cardioversion with DC shock are common, short living and do not carry clinical significance. They are related to the monophasic or biphasic configuration of DC shock, to the use of propofol, to the ejection fraction and to an increased CRP.

Cardiovascular safety profile of IPI-504 (retaspimycin hydrochloride), a novel Hsp90 inhibitor: Results from two independent phase I trials in patients with advanced cancer

e14539 Background: Heat shock protein 90 (Hsp90) is a protein chaperone that regulates the proper folding, stability, and function of multiple mutated and wild type signaling proteins that promote malignant phenotypes. Numerous clinical trials are investigating the activity of the Hsp90 inhibitor IPI-504. Since Hsp90 is a novel cancer target that is ubiquitously expressed in normal cells, a comprehensive evaluation of potential cardiac effects, including the risk of ventricular arrhythmia, was performed in two Phase I trials. Methods: ECG data were pooled and analyzed from 60 pts in two-open label Phase I trials of patients with advanced cancers. Pts received 90 to 400 mg/m2 of IPI-504 IV twice weekly for 2 out of 3 weeks. Subset analyses for 35 pts who received the MTD of 400 mg/m2 were performed. ECGs were obtained in triplicate at 5, 60, and 360 minutes after IPI-504 infusion. Interpretation was conducted at a central, independent laboratory. Results: Over 6,500 ECGs were obtained from 60 pts. At the MTD 3,000 ECGs were obtained from 35 patients. No ventricular arrhythmias or changes in QTcF of ≥60 msec were noted, and no statistically significant relationship between the concentration or dose of IPI-504 and QTcF was observed. At the MTD 5 minutes post infusion, changes from baseline were observed in QTcF (5.4 ms increase), heart rate (15.2 bpm decrease), and PR interval (27.9 ms increase). All of these changes reversed by 6 hours post-infusion and no clinical hemodynamic disturbances were observed. Conclusions: In phase I studies, IPI-504 was not associated with any significant ventricular arrhythmia and no clinically significant QTcF interval changes were noted. These studies did show however that IPI-504 administration was associated with transient, dose-related bradycardia and PR interval lengthening, suggestive of autonomic effects associated with the drug infusion. No clinically significant and IPI-504 related cardiac safety events were observed at the MTD dose of 400 mg/m2. Given these findings, appropriate monitoring of heart rate immediately post-infusion is recommended during further studies with IPI-504. [Table: see text]

Proliferation signal inhibitors and cardiac allograft vasculopathy

Cardiac allograft vasculopathy (CAV) is the leading cause of late morbidity and mortality in heart transplant patients and limits long-term survival. Immunosuppression following cardiac transplantation has traditionally comprised a calcineurin inhibitor in combination with mycophenolate mofetil or azathioprine and corticosteroids. This combination provides effective immunosuppression but does not prevent subsequent development of CAV. Proliferation signal inhibitors (such as sirolimus and everolimus), a new class of immunosuppressants, have recently been shown to be effective in attenuating the development of CAV following cardiac transplantation. In addition to immunosuppressive properties, proliferation signal inhibitors have important antiproliferative effects outside the immune system. Several ex-vivo and preclinical studies on animal models have demonstrated control of the vascular manifestations after cardiac transplantation. In clinical trials, proliferation signal inhibitors used as secondary immunosuppressive agents in place of azathioprine or mycophenolate prevented CAV progression and reduced the incidence of clinically significant cardiac events. Proliferation signal inhibitors are also effective as primary immunosuppressants, and, after complete calcineurin inhibitor withdrawal, mitigate the progression of CAV, improve calcineurin inhibitor-induced nephropathy and hypertension. Proliferation signal inhibitors are powerful immunosuppressive agents with antiproliferative properties that attenuate CAV and have the potential to improve long-term survival following cardiac transplantation.

82: Two Year Clinical Follow-up of Coronary Computed Tomography: Patients without Coronary Stenosis Show a Significant Lower Cardiac Event Rate than Predicted by Framingham Risk Score

82: Two Year Clinical Follow-up of Coronary Computed Tomography: Patients without Coronary Stenosis Show a Significant Lower Cardiac Event Rate than Predicted by Framingham Risk Score

High-Density Lipoprotein Cholesterol, High-Density Lipoprotein Particle Size, and Apolipoprotein A-I: Significance for Cardiovascular Risk: The IDEAL and EPIC-Norfolk Studies

This study was designed to assess the relationship of high-density-lipoprotein cholesterol (HDL-C), HDL particle size, and apolipoprotein A-I (apoA-I) with the occurrence of coronary artery disease (CAD), with a focus on the effect of very high values of these parameters. High plasma levels of HDL-C and apoA-I are inversely related to the risk of CAD. However, recent data suggest that this relationship does not hold true for very high HDL-C levels, particularly when a preponderance of large HDL particles is observed. We conducted a post-hoc analysis of 2 prospective studies: the IDEAL (Incremental Decrease in End Points through Aggressive Lipid Lowering; n = 8,888) trial comparing the efficacy of high-dose to usual-dose statin treatment for the secondary prevention of cardiovascular events, and the EPIC (European Prospective Investigation into Cancer and Nutrition)-Norfolk case-control study, including apparently healthy individuals who did (cases, n = 858) or did not (control patients, n = 1,491) develop CAD during follow-up. In IDEAL, only HDL-C and apoA-I were available; in EPIC-Norfolk, nuclear magnetic resonance spectroscopy-determined HDL particle sizes were also available. In the IDEAL study, higher HDL-C proved a significant major cardiac event risk factor following adjustment for age, gender, smoking, apoA-I, and apoB. A similar association was observed for HDL particle size in EPIC-Norfolk. Increased risk estimates were particularly present in the high ends of the distributions. In contrast, apoA-I remained negatively associated across the major part of its distribution in both studies. When apoA-I and apoB are kept constant, HDL-C and HDL particle size may confer risk at very high values. This does not hold true for very high levels of apoA-I at fixed levels of HDL-C and apoB. These findings may have important consequences for assessment and treatment of CAD risk.

Vinflunine in combination with trastuzumab for treatment of HER2-positive metastatic breast cancer

1058 Background: Vinflunine (VFL) is a microtubule inhibitor of the vinca alkaloid class with high activity in several tumour types especially in second line treatment of metastatic breast cancer (MBC). Over-expression of HER2 is observed in 20–25% of all breast cancers and is associated with a poor prognosis. The development of the anti-HER2 therapy with trastuzumab (T) allowed significant prolonging of the survival in HER2 positive MBC. The combination of these two compounds which are separately active in MBC warranted a combination study. Methods: This phase I was designed to determine the recommended dose (RD) of VFL in combination with T for treatment of first or second line MBC patients (pts), to assess its safety profile, and to determine its antitumour activity. Results: Thirty pts, median age 55 [33–74] years, WHO performance status 0/1: 18/12 pts , respectively were given VFL 280 mg/m2 (10 pts) or 320 mg/m2 (20 pts) day 1 every 3 weeks (w) in combination with T (loading dose 4 mg/kg and subsequently 2 mg/kg/w). Six pts were chemonaive and 5 pts received this combination in second line. At the first VFL dose (280 mg/m2), 0/6 pts experienced dose-limiting toxicity. The RD was established at 320 mg/m2 in the following 6 pts. All 30 pts are evaluable for safety. Haematological toxicities were: anaemia grade (G) 3: 0 and 1 pt; neutropenia G 3/4: 5/17 pts, febrile neutropenia 0/2 pts with VFL 280 and 320 mg/m2, respectively. G 3 non-haematological adverse events were only reported in the 20 pts receiving VFL 320 mg/m2: fatigue and myalgia: 5 pts; constipation: 4 pts; abdominal pain, neutropenic infection: 2 pts. ileus, hyponatremia, arthralgia: 1 pt. No significant cardiac events were observed. The response rates, 62.5% [95% confidence interval: 24.5–91.5] and 73.7% [95% confidence interval: 48.8–90.9] in pts receiving VFL at 280 mg/m2 and 320 mg/m2 respectively, were established by an external radiologist using RECIST in the first 27 evaluable patients. Conclusions: Vinflunine/trastuzumab combination is feasible with encouraging response rates and manageable toxicity in MBC pts. A phase III study comparing VFL + T versus paclitaxel + T has been initiated. No significant financial relationships to disclose.

Nonemergent coronary angioplasty without on-site surgical backup: A randomized study evaluating outcomes in low-risk patients

Background Percutaneous coronary intervention (PCI) in nonemergent patients with coronary artery disease in hospitals without on-site cardiac surgery backup is still controversial. To prospectively evaluate a set of low procedural risk criteria for PCI, patients with stable or unstable angina were randomized to treatment in either a community hospital, which had all supportive services except for on-site cardiac surgery, or a regional surgical hospital 213 km away. Methods and results During a 4-year period, 609 (57%) of 1064 consecutive patients with stable or unstable angina who underwent coronary angiography at a teaching community hospital in Norway fulfilled the predefined low-risk criteria for PCI. The patients were randomized to treatment at either the community hospital (n = 305) or at the regional hospital (n = 304). The angiographic success rate (96% at both hospitals) and number of major periprocedural complications (overall 0.3%) were equal at the 2 hospitals. In particular, there were no deaths or need for urgent transfer to cardiac surgery. At 6 months of clinical follow-up, there was a significant higher major adverse cardiac event rate rate at the community hospital, compared with the regional hospital (6.9% vs 2.3%, respectively, P = .03) because of more repeat target vessel revascularizations. Improvement in angina functional class and exercise capacity was similar in both groups. The excluded high-risk PCI patients had higher 6-month major adverse cardiac event compared with all low-risk patients (8.4% vs 4.3%, respectively, P = .01). Conclusion Selected nonemergent patients can, based on angiography, safely undergo PCI at hospitals without cardiac surgery backup. The angiographic selection criteria identified high-risk patients, which had worsened outcome at 6 months of follow-up.

Droperidol, when used for sedation during ERCP, may prolong the QT interval

Droperidol is a known effective adjunctive agent for sedation/analgesia during endoscopic procedures, particularly in patients who are difficult to sedate with narcotics and benzodiazepines alone. However, the Food and Drug Administration (FDA) warning about potential droperidol-related fatal cardiac arrhythmias, issued in December 2001, led to concern about its safety in current clinical practice. In this study, we evaluated the effects of droperidol on the Bazett's corrected QT interval (QTcB) administered to patients undergoing ERCP and frequency of cardiac arrhythmias. We retrospectively reviewed the medical records of patients who, at our institute, underwent ERCP while under sedation/analgesia and who received droperidol. Our protocol for patients who are considered to be candidates for droperidol use includes obtaining an ECG before and 1 to 3 hours after the procedure. From April 2002 to October 2004, 6292 ERCPs were performed, of which 3113 patients with normal baseline QTcB (2001 women, 1112 men) received droperidol. Mean dosages were 4.3 mg (range, 1.25-10 mg) in women and 4.5 mg (range, 1.25-13.75 mg) in men. A total of 233 patients (7.48%; 133 women, 100 men) developed QTcB prolongation. Mean increases of the QTcB above the upper limit of normal were 16 milliseconds in women (range, 1-194 milliseconds) and 22 milliseconds in men (range, 1-310 milliseconds). Of these, 15 patients (0.48%; 8 women, 7 men) had marked prolongation of the QTcB (defined QTcB, >500 milliseconds). No serious dysrhythmias occurred. Droperidol at usual doses during sedation/analgesia may precipitate QTcB prolongation above the normal range. However, no QT-related arrhythmias were noted in this study. Clinically significant cardiac events are probably rare with droperidol, despite documented QTcB effects. Baseline electrocardiogram for excluding patients with prolonged baseline QTcB and 1 to 3 hours afterward monitoring appears adequate when using droperidol. The study is still too small to detect very infrequent arrhythmia events.

Pharmacotherapy for Overactive Bladder

Multiple drugs are now available for the treatment of overactive bladder. Currently, the pharmacological approach is to deal with the problem at the neuromuscular junction by attempting to stop the activity of the neurotransmitter with antimuscarinic medications. This article reviews the positive and negative aspects of the agents that are currently available for use in the US. In randomised clinical trials, extended-release formulations of these agents appear as effective as the immediate-release formulations, but are associated with fewer adverse effects. Attempts to use entities that are muscarinic M(3) selective antimuscarinic agents have not significantly improved the efficacy, but have reduced the major adverse effect of excessively dry mouth. Dose escalation or titration is addressed to enhance efficacy further. None of these drugs appear to cause significant cardiac or CNS adverse events. This supports the continued use of these agents for overactive bladder symptomatology, as they appear to be effective in reducing symptoms and remain generally well tolerated.